The Baldrige Performance Excellence Program

Shaw, P. & Elliott, C. (2012). Quality and Performance Improvement in Healthcare. 5th Edition. (pgs. 156, 157, [VitalSource Bookshelf version]. Retrieved from

The successful evolution of this organizational structure in a competitive marketplace has required a close partnership between managers and physicians supported by a culture of physician group accountability for quality and efficiency. An overarching agenda for achieving excellence focuses on high-impact health conditions, provides goal-oriented tools to analyze population data, proactively identifies patients in need of intervention, supports systematic process improvements, and promotes collaboration between patients and professionals to improve health.

This paper will propose how TriCity Medical Center will monitor performance, achieve regulatory and accreditation compliance, and improve overall organizational performance. It will describe ways TCMC will communicate with leadership to ensure alignment of organizational goals and gain buy-in from staff to achieve compliance with the standards and requirements issued by regulatory and accreditation bodies. Also it will determine how compliance with the regulations and development of risk- and quality-management systems for the organization contributes to the organization’s overall performance-management system.

Various internal and external factors influence quality management and outcomes in hospital organizations. One internal factor that affects quality management and outcomes is leadership within the organization. Leadership is important to have successful quality management outcomes because if the leadership does not support it, no change within the organization will be successful. “This commitment must be shared by the board of trustees and all senior clinical and administrative managers and understood that it is a long-term process” (Chassen and Leob, 2011). Leadership is one of the most influential internal parts of the quality management program. Leadership can either help the organization succeed with their support or help the organization fail if they do not support and follow

NAHQ is dedicated to the advancement of healthcare quality and patient safety and the professionals working in the field. “These professionals drive the delivery of vital data for effective decision making in healthcare systems by combining technology with their unique expertise in quality management” (NAHQ, n.d.). Also, at NAHQ, these healthcare quality professionals are provided with resources and tools that expand knowledge and skills in the competency areas that require advance quality. This helps the strategic leaders in achieving regulatory, accreditation and organizational compliance in quality and safety improvement

Quality management is essential to the success of the quality improvement of the health care industry. “Management uses management and planning tools to organize the decision making process and create a hierarchy when faced with competing priorities “( Ransom, et al., 2008). Quality measures should have these goals: effective, safe, efficient, patient-centered, equitable, and timely care (Quality Measures, Center for Medicare & Medicaid Services, 2011).

Experienced clinician will drive the efforts to maximize the Medicare CMS STARS rating and will collaborate with organizational stakeholders to develop a multi-year strategy. Development of performance improvement strategies will include the development and analysis of reports and leading Member Perception projects, implementing new initiatives to improve Star ratings. Manager will monitor initiatives and progress in the Clinical, Pharmacy and Provider workgroups.

My experience in both my previous career in nursing and human resources has dealt with approaches in quality improvement in patient safety and different metrics in the turning up organizational behavior as well as up swinging the operations of the organizations respectively. We live in a rapidly changing world, and healthcare industry is not exempted from it. Because I will be playing an indispensable role in the future, I am very interested on the concept of quality improvement and what not and identify possible future challenges and draw lessons from healthcare organizations that has spearhead innovative changes to providing healthcare by pursuing the triple dimensions of the improvement of healthcare in general that is Improving the patient experience of care (including quality and satisfaction); Enriching the health of populations; and Reducing the per capita cost of health care.

Evidence-based management means that operational and strategic decisions are made based upon the evidence that goals and objectives are actually being met. Quantitative measurements must be identified and measured. This data is then used to evaluate the HCO’s performance. Name three (3) performances Middleville can use to measure its success in providing quality healthcare to the community, and identify quantifiable, measurable indicators that can be used to do so. Explain the importance of each performance measurement.

al., 2012). Trying to get the leadership motivated with adapting to TQM was a challenge in the beginning. The enthusiasm of top leaders has caused the TQM process to become effective. Although Health care has a complex adaptive system, leadership is crucial in implementing an improvement system (Sollecito & Johnson, 2013). The strengths of the TQM process were the support of the chamber of commerce, implementation of a quality improvement plan, adapting a successful way to measure improvement and development of cost effective techniques (McLaughlin, et. al., 2012). Corporate headquarters was totally involved in the TQM program with the CEO John Kausch as an active member of the Total Quality Council of the Pensacola, Area Chamber of Commerce (McLaughlin, et. al., 2012)

Performance management relates to an organization’s ability to implement a system to evaluate and advance employee performance. Achieving peak performance requires consistency, clear objectives, and constructive employee evaluation. According to Mithas, Ramasubbu, & Sambamurthy (2011), an organization must design the performance management system based on extensive research about the organization’s mission, and then properly communicate the purpose of the system to employees, stakeholders, and decision makers. After the performing the research, the information should be used to establish the appropriate performance management specialized for the organization. In addition, an effective performance management system should align

The Malcolm Baldrige National Quality Award is the highest level of national recognition for performance excellence that United States organization can receive. Being that an organization has received the highest level of recognition that can be reached. When a patient is aware of that, they would continue being a client to the facility. People want the best quality of service that one can receive. Therefore, a facility that is a recipient of such award customer base is going to rise. A study between Baldrige hospitals and Non-Baldrige hospitals was done and showed a significant difference. A Baldrige hospital Patient Safety Index was 58.230 versus Non-Baldrige hospital was only 50.010. The severity-adjusted average length of stay was 59.280

To determine if the system is successful it must be measured against a specific set of standards and them it must be determined at what level those standards have been reached. First, the organizational impact of the system must be determined. This can be evaluated by asking the following questions: Has a higher level of quality care been obtained? Have financial benefits been

Benchmarking is a powerful tool used to promote continuous improvement of an organization. It enables the decision-makers to realize how much improvement is required to achieve satisfactory performance. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has defined benchmarking as “a measurement tool for monitoring the impact of governance, management and clinical and logistical functions” (as cited in Ettorchi-Tardy, Levif & Michel, 2012). There are four different kinds of benchmarking: internal, external or competitive, functional and generic or best practice. Also, there are several benefits of using benchmarking within healthcare organizations such as improving the quality of patient care, encouraging accountability among providers, improving productivity, yielding greater efficiency, meeting accreditation requirements, etc.

Fixing problems that face health care in many health facilities demand a system wide set of solutions. The systems used in these facilities must be assessed and redesigned to identify factors that will aid in the achievement of the set goals. The enormous task of achieving the goals should be undertaken collaboratively by all the key stakeholders, who include, health care professionals, planners and policy makers, administrators, payers, and patients and their families. These partnerships must begin with a common understanding of the problems together with a shared commitment to cooperate and work together to eliminate the problems. With this knowledge, therefore, an action plan for redesigning the health care system can be developed and later implemented. For a successful health care service to be realized, there are various factors which should be employed and which are not found in the traditional business setting. These include unique economic processes, proper regulatory requirements and the perfect quality indicators. This creates a need for every leader within the healthcare industry to create or develop unique skill sets that will harmonize both organizational leadership and the inter-professional team development. It is, therefore, important to understand the comprehensive approach to the management of patient care and also how the concepts of team development and organizational leadership support healthcare leaders in creation of a patient-centric